PROVO — Ogden Police Department investigators concluded the mistakes made by Provo 911 dispatchers on the October night Scott Aston died were procedural and criticized the dispatch center for sloppy implementation of policies, according to an Oct. 26 report released Monday by Provo.
The report had been sought for months by media outlets and Aston family members, who said being able to read it at last during a mediation session with city officials last week was a key reason they chose to accept Provo's $220,000 settlement offer rather than sue the city.
Aston's sister, Carol Davis, said the report vindicated her position that dispatchers treated her brother like a prank caller and that there were problems in the dispatch center, but she also said seeing the report alleviated her concerns that there might have been more sinister errors.
Aston called 911 from his cell phone and told the dispatcher who fielded the call that he was dying. Cell phone calls can't be traced by Provo's dispatch center, but the two dispatchers who worked on the case made more than half a dozen errors during Aston's 3 1/2-minute call, and he died after emergency personnel were unable to find him.
"It appeared to the investigators that this call quickly became just another bad-address, non-emergency call," the report said. "This indicates a high level of complacency on the part of the center personnel."
Davis expressed gratitude to city officials for the release of the documents and for the settlement. She also agreed with Provo Mayor Lewis Billings that several improvements have been made at the center that have saved at least one life and could save more.
A few weeks ago, a man in diabetic shock called 911 from his cell phone and said he was in his car somewhere in Provo. Because of his condition, he couldn't provide his location. Dispatchers, police and fire department personnel worked together until they found him on a roof where he'd been doing some work.
They found him because they contacted the caller's cell phone provider — something not done the night Aston died — and learned that the call originated in a corridor along 900 West just north of Center Street.
"If we have someone on the phone and for some reason we lose contact with them," Billings said, "that can't just be noted in the log or the record. (Dispatchers) have to at that point advise a battalion chief or a police watch commander. Those are the people who have to determine when we have done enough."
That's just one of many new policies at the dispatch center, but the largest change will be the implementation of enhanced 911 service, which will allow dispatchers to trace cell phone calls. Provo plans to have the system in place by the end of 2005 or soon after, spokeswoman Raylene Ireland said. The rest of Utah is on a similar timeline.
Setting up the system will cost up to $350,000, which Provo already has built into its budget.
Ogden's report said one or both of the dispatchers in the Aston case failed to ask Aston his name, didn't verify his address numerically, didn't follow other procedures outlined for Medical Priority Dispatches, editorialized to emergency responders that Aston was fine, didn't catch the name of his apartment complex when he provided it, told responders the call was disconnected while they were still talking to Aston, didn't provide responders with what they thought might be his name when they called him back and got his voice mail and, finally, didn't ask others to listen to a tape of the call.
The dispatcher who took the call was a reserve dispatcher. He was effectively terminated by Provo but continues to work for Utah County. The other dispatcher, a woman, was disciplined but continues to work for Provo.
Most of those findings had already been disclosed to the public by Provo officials during a March press conference. But the full document added the weight of the opinions of Ogden's outside investigators.
"There is no evidence of deliberate malfeasance on the part of any employees of Provo city, and the investigators are comfortable that the incident does not demonstrate a history of procedural errors on the part of the Provo Police Department's Dispatch Center," the report said.
However, the report stated later, "The Provo City Communications Center Operations Policy manual is haphazard and disorganized. . . . It appears to contain most of the right information, but there is no way to rapidly locate the information, and the appropriate information is spread throughout various documents."
Aston family attorney Justin Heideman said the $220,000 settlement was about the maximum the family could have expected to net after appeals if it had filed a lawsuit and won a $535,000 verdict, the maximum allowable under Utah law because of a government immunity statute.
"The Governmental Immunity Act is a real problem in Utah," Heideman said. "It was not drafted to protect citizens. It is designed to protect municipalities even from intentional wrongdoing. That doesn't seem right."
The city repeatedly said the Ogden report was part of an internal affairs investigation and was protected by law. The Astons argued the information was fundamental to their ability to obtain closure. When the city offered to show the family the report during last week's marathon mediation session, the family agreed, and the city determined it could then release the document.
Also released were statements made by four dispatchers, at least three of whom were present on the night of the call. The dispatchers' names were redacted both from the report and the statements they gave to investigators.
"This is a great tragedy and I am very sorry it occurred," the female dispatcher wrote. "In looking back on the incident I do feel that I was not doing everything I could because I was under the impression that the call was not that serious."
A third, uninvolved dispatcher who overheard the two working on the call expressed concern about the way each of them handled themselves. She paraphrased the male dispatcher's reaction to the end of Aston's call: "He hung up when I tried to confirm his address. He said he was dying. What can I do with that?"
A Utah medical examiner was unable to determine Aston's cause of death. City officials and Aston's family agreed that it is impossible to know if medical personnel could have saved him.
Billings expressed regret for the errors but also confidence in the dispatch center.
"The public has come in to really scrutinize it in great detail," Billings said. "I think they've had opportunity to see right to the bottom and see everything there was, and there was an error, but there are good people trying hard to do a good job, and they deal with so many things in a stellar way."
E-mail: twalch@desnews.com